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Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits.

Availability of counseling support services was also a driver of choice. Facility type, i. Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Funding: Funding for this research was provided by the U. The findings and conclusions in this paper are those of the author s and do not necessarily represent the official position of the U.

Competing interests: The authors have declared that no competing interests exist. This ambitious plan was informed by the dramatic decrease in pediatric HIV and HIV-related maternal deaths in wealthy countries through universal HIV testing of pregnant women and use of antiretroviral treatment ART for eligible women. Ethiopia and Mozambique have an estimatedand 1.

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Rates of HIV transmission from mother to child are high; in9, children were newly infected in Ethiopia and 14, were infected in Mozambique Table 1 [ 89 ]. At the same time, both countries suffer from severe health worker shortages, with health worker-population ratios of 0. Compared to women starting ART for their own health i.

The authors suggest a of reasons for lower retention, including that women at earlier stages of HIV disease perceive themselves as healthy and thus not in need of treatment, reluctance to disclose HIV status to family, and lack of support and counseling in busy clinics [ 1213 ]. These emerging concerns about retaining patients in lifelong treatment underscore the importance of identifying what HIV-infected women want from the health system and how services can best be organized to promote their retention in care and to optimize health outcomes.

This is particularly urgent in resource-constrained settings where trade-offs in health system investments will inevitably be required. DCEs can be used to present hypothetical health care scenarios, each with different attributes e. From these data the relative importance of each attribute can be estimated. One advantage of DCEs is the ability to test services and de changes ahead of their implementation [ 1516 ]. We conducted two discrete choice experiments DCEs in Ethiopia and Mozambique to identify the preferences of HIV-infected women of childbearing age for attributes of outpatient visits for ART in the context of lifelong care.

Facilities selected for the study were the four ICAP-supported facilities with the greatest volume of patients on ART in their respective regions, with between 1, to 3, women actively enrolled in ART at each site in [ 22 ].

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For this study, we recruited HIV-infected women aged 15 to 49 who were receiving care in selected clinics and who were either pregnant or indicated their intention to have children in the future. Participants were recruited from ART clinics, antenatal care ANC clinics, and in Mozambique, from clinics providing services for children born to HIV-infected women and their mothers as well as other high-risk groups. Researchers selected a systematic random sample by inviting women who were exiting their clinic appointments to participate in the study at regular time intervals during clinic operating hours.

All eligible women were informed of the purpose of the study and their right to refuse participation. Interviews were performed after receipt of written consent from the participant or, in the case of minors, upon receipt of assent from the participant and consent from the guardian. Where possible, similar attributes were selected to permit comparison between study findings in Mozambique and Ethiopia. Subsequently, we conducted four focus groups in each country with HIV-infected women in the reproductive age group in a subset of study clinics to narrow down the attribute list.

Based on these rankings, we identified two sets of attributes and levels for the DCE, one each for Mozambique and Ethiopia. The final attributes were: type of facility hospital, clinic, and in Mozambique, mobile clinicprovider attitude, availability of integrated non-HIV health services e. Cost of visit was included to permit estimation of willingness to pay. Though care and treatment for HIV infection is provided free of charge in both countries, women may bear other costs, such as transportation, food, and, if purchased privately, medications.

The attributes and levels generated possible alternatives in Ethiopia and alternatives in Mozambique, which is too many for women to evaluate. Thus, we selected a fractional set of 16 alternatives or 8 choice sets using experimental de that maximized D-efficiency in Sawtooth Software, a software program for deing discrete choice experiments [ 2324 ].

To further enhance statistical efficiency and maximize study power we used five different versions of the DCE in each country.

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Each participant was presented with 9 choice cards, each showing two health facilities. Each choice scenario was accompanied by a standardized script, which was read by the interviewer. We constructed a relative index of household wealth status using principal component analysis of a set of 20 questions on household assets [ 25 ].

The survey and consent forms were developed in English, translated to Portuguese in Mozambique, and Affan Oromo and Amharic in Ethiopia, then back-translated to English and pre-tested to ensure accuracy. The surveys were piloted, revised, and administered by trained interviewers.

The interviews lasted 45 to 60 minutes and were conducted using hand-held electronic tablets with SurveyCTO software Dobility, Inc. Data were collected over a period of 8 weeks 16 April to 14 June in Ethiopia, and 8 April to 6 June in Mozambique. Data were cleaned typographical errors corrected, variables recoded as necessary and transferred to Stata v. We calculated descriptive statistics for survey variables.

Mixed logit models are commonly used to analyze discrete choice data as they for taste heterogeneity by allowing attribute coefficients to vary across respondents; they also control for intra-individual correlations due to repeated responses [ 26 ]. The unconditional probability of the observed sequence of choices for a given choice set t is given by. Probabilities were estimated with a simulated maximum likelihood estimator. The output of a mixed logit model includes mean attribute utilities and standard deviations of the random coefficients, the latter reflecting the degree of preference heterogeneity among respondents.

In all models, as per standard practice, costs of the visit were specified as fixed to ensure ease of interpretation of willingness to pay, and all other variables were specified as random [ 27 ]. Of 1, women eligible to participate in Ethiopia, 1, participated in the survey, for a response rate of In Mozambique, 1, of 1, eligible women participated in the survey, for a response rate of Demographic and health characteristics of the respondents are summarized in Table 3.

The mean age was Most respondents were on ART at the time of the interview Women known to be pregnant at the time of the interview comprised Among our sample, 55 5. The length of diagnosed HIV infection calculated as the difference between the self-reported date of first HIV diagnosis and date of interview among these women was shorter than for women on treatment for their own health mean of months since HIV diagnosis in Ethiopia: Their average age was Utility estimates for DCE attributes are shown in Table 4.

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In the main effects model, five of the attributes—provider type, provider attitude, availability of non-HIV services in the same consultation, availability of counselor, availability of mother support groups Ethiopia onlyinvolvement of husband or family in care Mozambique only —had positive mean coefficients representing positive preferences for these attributes. As expected, increasing cost had an aversive effect on preference, indicated by the negative coefficient.

Our models correctly predicted a high proportion of alternatives selected in the fixed choice cards: The two most important attributes for women in both countries were respectful provider attitude and availability of non-HIV services such as blood pressure measurement, newborn care and family planning in the same consultation. This means that women place relatively less emphasis on type of health facility where they obtain HIV care, holding all other attributes constant.

Pregnant women in Ethiopia valued mother support groups more than did non-pregnant women, and in Mozambique they valued respectful providers more than did non-pregnant women. In Mozambique the involvement of husband or family was less important to pregnant women than to their non-pregnant counterparts. Analyses with interaction terms for ART status indicate that in Ethiopia there were no differences in preferences between women currently on ART vs.

In Ethiopia, these women valued mother support groups and receiving care at hospitals vs. Lastly, analysis that included interaction terms between service attributes and young age under 25 years show no differences between younger women and older women see S1 — S4 Tables. Analysis of dominant attributes, i.

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We elected to retain these respondents in the analysis as a dominant or non-trading response pattern may be consistent with random utility theory and deleting these responses may thus remove valid information about preferences. Removing respondents with dominant preferences can also induce selection bias, reducing generalizability to the broader population, and reduce statistical efficiency of the model [ 28 ].

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We found that HIV-infected pregnant women and women desiring a future pregnancy in Ethiopia and Mozambique placed greatest value on respectful providers and the ability to obtain non-HIV services in their clinic visits for HIV treatment. To illustrate the magnitude of preference, these two service attributes were approximately twice as important to Ethiopian women as the availability of mother support groups and counseling services.

Additional analysis showed that the utility of respectful providers was even greater for pregnant women in Mozambique than non-pregnant respondents.

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The high value for provider respect is consistent with DCE studies of obstetric care: women in Tanzania and Ethiopia were highly influenced by having a respectful provider in deciding between hypothetical facilities for delivery [ 2930 ]. Women in both countries in our study highly valued the ability to obtain needed non-HIV related services in their HIV clinic visit.

This suggests that women would like to improve the efficiency of their encounters with the health system, a particularly trenchant concern given the need to return to clinic many times for HIV care and treatment [ 31 ]. This highlights the importance of better organizing outpatient care to permit access to more than one service and is consistent with recent PEPFAR priorities that promote integration, sustainability and coordination between countries [ 32 ]. While much has been written on the benefits and costs of integration of HIV services with other health care, the finding that clients with HIV might choose their facility based on convenient access to a range of services is novel and of substantial policy relevance [ 33 — 35 ].

Availability of counseling, mother support groups Ethiopiaand counseling and providers who involved the husband or family in care Mozambique were positively associated with clinic preference. Pregnant women in Ethiopia had a stronger preference for mother support groups than non-pregnant respondents.

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The value placed on peer support is consistent with the work of Assefa et al. Pregnant respondents in Mozambique indicated a lower preference for provider efforts to involve the husband and family compared to non-pregnant women. Reluctance to disclose HIV status is likely influenced by prevailing stigma [ 3738 ]. However, more work is required to understand how this might differ for pregnant versus non-pregnant women and how clinicians can support disclosure in settings where stigma remains a reality.

Mozambique is currently considering the introduction of peer support groups to promote adherence and reduce stigma. Our findings from Ethiopia buttress this as mother support groups were valued by respondents there. Study participants in both countries indicated that the type of facility—hospital versus health center or mobile clinic in Mozambique was much less important to them than other factors. This is reassuring for policymakers as decentralization of HIV care to health centers and clinics is proceeding rapidly in both countries.

The important caveat is that the indifference to service setting is conditional on receiving other valued attributes on the list: respectful care, access to non-HIV services, counseling, etc. The study had several strengths. This is the first discrete choice experiment exploring preferences for lifelong receipt of HIV treatment.

Finally, the robustness tests that compared model-predicted with actual choices of DCE facilities suggested that the experiment was well specified, capturing important drivers of preference. This study had also several limitations. The non-DCE variables were self-reported and are subject to recall bias.

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Second, the study was done in a limited of facilities in Ethiopia and Mozambique and the cannot be extrapolated to other populations. However, the concordance of preferences across the two countries, particularly the strong preference for the top two attributes, suggests our findings may be applicable to demographically and geographically comparable populations facing similar health systems challenges.

Third, interviews were only conducted with women at health facilities, and the vast majority of participants were already receiving ART. Therefore we could not capture HIV care preferences of infected women who are not yet diagnosed or have discontinued care.

Discrete women only

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